Pelvic Organ Prolapse

Pelvic Organ Prolapse

Topic Overview

What is pelvic organ prolapse?

Pelvic organ
prolapse occurs when a pelvic organ—such as your bladder—drops (prolapses) from
its normal place in your lower belly and pushes against the walls of your
vagina. This can happen when the muscles that hold your
pelvic organs in place get weak or stretched from childbirth or surgery.

Many women will have some kind of pelvic organ prolapse. It can
be uncomfortable or painful. But it isn't usually a big health problem. It
doesn't always get worse. And in some women, it can get better with time.

More than one pelvic organ can prolapse at the same time. Organs
that can be involved when you have pelvic prolapse include the:

What causes pelvic organ prolapse?

Pelvic organ
prolapse is most often linked to strain during childbirth. Normally your pelvic
organs are kept in place by the muscles and tissues in your lower belly. During
childbirth these muscles can get weak or stretched. If they don't recover, they
can't support your pelvic organs.

Pelvic organ prolapse can be made worse by anything that
puts pressure on your belly, such as:

  • Being very overweight (obesity).
  • A long-lasting cough.
  • Frequent constipation.
  • Pelvic organ tumors.

Older women are more likely to have pelvic organ
prolapse. It also tends to run in families.

What are the symptoms?

Symptoms of pelvic organ
prolapse include:

  • Feeling pressure from pelvic organs pressing against the
    vaginal wall. This is the most common symptom.
  • Feeling very full in your lower belly.
  • Feeling as if something is falling out of your vagina.
  • Feeling a pull or stretch in your groin area or pain in your
    lower back.
  • Releasing urine without meaning to (incontinence), or needing
    to urinate a lot.
  • Having pain in your vagina during sex.
  • Having problems with your bowels, such as constipation.

How is pelvic organ prolapse diagnosed?

Your
doctor will ask questions about your symptoms and about any pregnancies or
health problems. Your doctor will also do a physical exam, which will include a
pelvic exam.

How is it treated?

Decisions about your treatment
will be based on which pelvic organs have prolapsed and how bad your symptoms
are.

If your symptoms are mild, you may be able to do things at
home to help yourself feel better. You can relieve many of your symptoms by
adopting new, healthy habits. Try special exercises (called
Kegels) that make your pelvic muscles stronger. Reach
and stay at a healthy weight.
Avoid lifting heavy things that put stress on your pelvic muscles.

If you still have symptoms, your doctor may have you fitted with a
device called a
pessary to help with the pain and pressure of pelvic
organ prolapse. It is a removable device that you put in your vagina. It helps
hold the pelvic organs in place. But if you have a severe prolapse, you may
have trouble keeping a pessary in place.

Surgery is another
treatment option for serious symptoms of pelvic organ prolapse. But you may
want to delay having surgery if you plan to have children. The strain of
childbirth could cause your prolapse to come back.

You may want
to consider surgery if:

  • You have a lot of pain because of the prolapsed organ.
  • You have a problem with your bladder and bowels.
  • The prolapse makes it hard for you to enjoy sex.

Types of surgery for pelvic organ prolapse
include:

  • Surgery to repair the tissue that supports a prolapsed organ.
  • Surgery to repair the tissue around your vagina.
  • Surgery to close the opening of your vagina.
  • Surgery to remove the uterus (hysterectomy).

Pelvic organ prolapse can come back after surgery. Doing
Kegel exercises to make your pelvic muscles stronger will help you recover
faster from surgery. The two together can help you more than surgery
alone.

Frequently Asked Questions

Learning about pelvic organ prolapse:

Being diagnosed:

Getting treatment:

Ongoing concerns:

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Cause

Pelvic organ prolapse is usually caused
by damage to the tissues (muscles, ligaments, and connective tissue) that
support the pelvic organs. Damage or stretching of these tissues allows the
organs to move out of their normal positions. This causes them to press against
(and sometimes move) the inside walls of the vagina.

Having a baby
makes it more likely that you will have pelvic organ prolapse later. Vaginal
childbirth has been strongly linked to weakened and stretched support
structures in the pelvic area. This loss of support is the biggest cause of
pelvic organ prolapse. Having a cesarean section, on the other hand, seems to
be less strongly linked to pelvic organ prolapse.

Another cause of
reduced support in the pelvis is lower levels of the hormone
estrogen. Estrogen levels are lower during and after
menopause. The lower levels of estrogen in the body
mean less
collagen, a protein that helps the pelvic connective
tissues stretch and return to their normal positions.

Other
conditions that may cause pelvic organ prolapse include:

  • Obesity, which can lead to long-term pressure within
    the abdomen.
  • Smoking and/or lung disorders, which are often causes of chronic
    coughing.
  • Conditions affecting the spinal cord, such as
    muscular dystrophy,
    multiple sclerosis, and spinal cord injury, that cause
    paralysis of the muscles of the pelvic floor.

Symptoms

Although many women who have
pelvic organ prolapse do not have symptoms, the most
common and bothersome symptom is pressing of the
uterus or other organs against the vaginal wall. The
pressure on your vagina may cause minor discomfort or problems in how your
pelvic organs work. Symptoms of pelvic organ prolapse include:

  • A feeling of pelvic pressure.
  • A feeling as if something is actually falling out of the
    vagina.
  • A pulling or stretching in the groin area or a low
    backache.
  • Painful intercourse.
  • Spotting or bleeding from the vagina.
  • Urinary problems, such as involuntary release of urine (incontinence) or a frequent or urgent need to urinate,
    especially at night.
  • Problems with bowel movements, such as constipation or needing
    to support the back (posterior) of the vaginal wall to have a bowel
    movement.

Symptoms of pelvic organ prolapse are made worse by
standing, jumping, and lifting and usually are relieved by lying down.

What Happens

The
pelvic organs are kept in place by the muscles and connective tissues of the
pelvis (pelvic diaphragm). The vagina of an adult woman is normally a
round-topped, muscular tube that also supports the other pelvic organs. The
pelvic muscles and tissues can be stretched or damaged, most commonly by
childbirth. When they don't recover, they lose their ability to support the
organs.

The location and severity of
pelvic organ prolapse is related to where in the
pelvis the injury or muscular damage has occurred. You may have several areas
of injury that contribute to prolapse. Prolapse may occur after surgery to
remove the uterus (hysterectomy) if the procedure removes
or damages support of the bladder, urethra, or bowel wall. If other conditions,
such as childbirth, damage muscles or nerves in the pelvis, the pelvic
diaphragm may lose its dome shape. It may become more like a funnel and then bulge
down into or out of the vagina.

Pelvic organ prolapse may increase
pressure on the vagina and interfere with sexual activity, sometimes leading to
sexual dysfunction. For more information, see the topic
Sexual Problems in Women.

Lower estrogen levels during and after
menopause make pelvic organ prolapse more likely.
Estrogen helps your body to make collagen, a protein that enables the
supportive tissues of the pelvis to stretch and return to their normal
positions. When estrogen levels go down, so do collagen levels. Less collagen makes it more likely that those supportive tissues
will tear.

Pelvic
organ prolapse may be a progressive condition, gradually getting worse and
causing more severe symptoms. But in many cases it does not progress and may
improve over time.

What Increases Your Risk

Pelvic organ prolapse is often
related to stretching and pressure during labor and childbirth. This can occur when a woman delivers a large baby [over 9 lb (4 kg)] or when she has a long, difficult labor and delivery. Pelvic organ prolapse most often appears during
menopause, as pelvic tissues damaged during
childbearing age and lose strength.

Other things that may
increase the risk for pelvic organ prolapse include:

  • Obesity. Women who are overweight have increased pressure in the
    abdomen and have a higher rate of pelvic organ prolapse.
  • Smoking and lung conditions that cause chronic coughing, which
    increases pressure in the abdomen and pelvis.
  • Constipation. Chronic constipation causes increased pressure from
    the bowel on the vaginal wall.
  • Certain occupations that require heavy lifting.
  • Diseases of the nervous system. Pelvic organ prolapse is more
    common in women who have
    multiple sclerosis,
    muscular dystrophy, or a
    spinal cord injury than in women who do not have such
    conditions.
  • Genetic factors. A weakness in the supportive tissue of the
    pelvis can be passed through families. If your mother or sister has had pelvic
    organ prolapse, you may be more likely to get it too.

When To Call a Doctor

Call your doctor to schedule an
appointment if:

  • You notice a bulge of tissue inside your vagina or bulging out of
    your vagina.
  • You have a sensation of pulling or increased pelvic pressure that
    is made worse when you strain or lift but is relieved when you lie down.
  • Pain in your low back or pelvic area is interfering with your
    daily activities.
  • Sexual intercourse has become difficult or painful.
  • You have irregular spotting or bleeding from the vagina.
  • Urinary symptoms, such as involuntary release of urine (incontinence), urinating frequently, having an urgent
    need to urinate, or urinating frequently at night, have developed and are
    interfering with your daily activities.
  • You have difficulty having a bowel movement.

Watchful waiting

Watchful waiting is a period of time during
which you and your doctor observe your symptoms or condition without using
medical treatment. This period may vary from a few days to weeks, months, or
years. If you have been diagnosed with
pelvic organ prolapse and you do not have symptoms, or
if you have mild symptoms that are not interfering with your daily activities,
you may wish to try watchful waiting. Many women who have pelvic organ prolapse
do not have symptoms, so they do not require treatment.

If
you have symptoms, such as a feeling of pressure in your vagina, schedule an
appointment with your doctor.

Who to see

Your doctor can evaluate symptoms caused by pelvic
organ prolapse. Pelvic organ prolapse can be diagnosed and treated by the
following health professionals:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

A prolapse of a pelvic organ is
sometimes difficult to diagnose.
Pelvic organ prolapse that does not cause symptoms is
often discovered during a routine exam. You may be aware that there is a
problem but be unsure of the exact location or cause. If prolapse is suspected,
your doctor will take your medical history, including your symptoms and your
history of pregnancies and other health problems, and do a physical exam,
including a
pelvic exam.

Tests may be done to
find out the nature of a prolapse, particularly if it is causing problems with bladder or bowel function. These tests include:

Doctors use a classification system to determine the level
of an organ's prolapse. Identifying the exact level of prolapse helps guide
decisions about which treatments are most likely to offer long-term success.
One standard
classification uses "stages" of prolapse and is based
on how close the lowest part of the organ is to the opening of your vagina (the
hymen).

Treatment Overview

Many women who have
pelvic organ prolapse do not have symptoms and do not
require treatment. If your symptoms are bothersome, you may want to consider
treatment. Treatment decisions should take into account which organs are
affected, how bad symptoms are, and whether other medical conditions are
present. Other important factors are your age and sexual activity.

Many women are able to reduce pain and pressure from a pelvic organ
prolapse with nonsurgical treatment, which may include making lifestyle
changes, doing exercises, and/or using a removable device called a
pessary that is placed into the vagina to support
areas of prolapse.

If your pelvic organ prolapse is causing pain
or problems with bowel and bladder functions or is interfering with your sexual
activity, you may want to consider surgery. Surgical procedures used to correct
different types of pelvic organ prolapse include repair of the supporting
tissue of the prolapsed organ or vagina wall. Another option is the removal of
the uterus (hysterectomy) when it is the prolapsed organ or if it
is causing the prolapse of other organs (such as the vagina).

Sometimes surgery cannot repair all the prolapsed organs. And sometimes
pelvic organ prolapse comes back after surgery.

Initial treatment

Pelvic organ prolapse can be a long-lasting condition. But it does not have to be a cause of symptoms that disrupt your life. Many
women with pelvic organ prolapse are able to relieve their symptoms without
treatment by adjusting their activities and lifestyle habits. These changes
might include:

  • Doing
    pelvic floor (Kegel) exercises every day to tighten
    and strengthen pelvic muscles.
  • Eating
    high-fiber foods to prevent constipation. Get at least
    20 g of fiber a day.
  • Reaching and staying at a healthy weight.
  • Avoiding activities that stress your
    pelvic muscles, such as heavy lifting.

If your symptoms are not relieved by these lifestyle
changes, you may want to consider treatment for pelvic organ prolapse.
Treatment will be different depending on which organs are involved, how bad
your symptoms are, and what other medical conditions are present. Treatment may
include using a
pessary, a removable device that is placed
into the vagina to support areas of prolapse.

Ongoing treatment

Pelvic organ prolapse can be a long-lasting condition. But it often responds to adjustments in activities and lifestyle habits. If you
have tried self-care, such as eating
high-fiber foods, staying at a healthy weight, and
doing
pelvic floor (Kegel) exercises, but your symptoms are
increasingly bothersome, you may want to consider nonsurgical treatment.
Treatment will be different depending on which organs are involved, how bad
your symptoms are, and what other medical conditions are present. Treatment may
include using a
pessary, a removable device that is placed
into the vagina to support areas of pelvic organ prolapse.

Treatment if the condition gets worse

If you have
pain and discomfort from
pelvic organ prolapse that does not respond to
nonsurgical treatment and lifestyle changes, you may want to consider surgery.
The choice of surgery depends upon which organs are involved, how bad your
symptoms are, and what other medical conditions are present. Also, your surgeon
may have experience with and preference for a certain procedure. Types of
surgery for pelvic organ prolapse include:

Often the doctor does more than one of these
surgeries at the same time. These surgeries are designed to treat specific
symptoms. So other symptoms may remain after surgery.

For help deciding about surgery, see:

Pelvic Organ Prolapse: Should I Have Surgery?

What to think about

If you are considering having
children, you may want to delay pelvic organ surgery. If you have surgery and
then deliver a child vaginally, the strain on your pelvic organs may cause them
to prolapse again.

Sometimes surgery cannot repair all the
prolapsed organs. And sometimes surgery to repair pelvic organ prolapse will lead to prolapse in another area.

Pelvic organ prolapse may be a progressive condition, gradually getting
worse and causing more severe symptoms. But in many cases it does not progress
and may improve over time.

Prevention

Pelvic organ prolapse is most often a result of tissue damage caused by labor and
childbirth. Although you may not be able to prevent the damage to your pelvic
organs caused by childbearing, you may be able to control the progression of
the prolapse. Lifestyle changes that may slow the prolapse process
include:

  • Reaching and staying at a weight that is healthy for your
    height.
  • Not smoking. The chronic cough associated with smoking may cause
    or speed pelvic organ prolapse.
  • Correcting
    constipation. The straining caused by constipation
    weakens and damages the connective tissue and muscles in the pelvis.
  • Avoiding heavy lifting and jumping.
  • Doing pelvic strengthening exercises (Kegel exercises)
    every day. These exercises help strengthen the muscles of the pelvis.

Home Treatment

Home treatment can relieve the
discomfort of
pelvic organ prolapse. It can also help to keep
prolapse from getting worse.

  • Do
    Kegel exercises every day to strengthen the muscles
    and ligaments of the pelvis.
  • Prevent or correct constipation. The straining caused by
    constipation increases pressure from the bowel on the vaginal wall and weakens
    and damages the connective tissue and muscles in the pelvis.

    • Try gentle exercise. Take a short walk each day. Gradually
      increase your walking time until you are walking for at least 20 minutes each
      day.
    • Make sure you drink enough fluids.
    • Eat plenty of
      high-fiber foods such as whole grains, fruits, and
      vegetables every day. Have a bran muffin or bran cereal for breakfast, and try
      eating a piece of fruit for an afternoon snack. Try to eat about
      20 g of fiber every day.
    • Schedule time each day for a bowel movement—after breakfast,
      for example. Having a daily routine may help. Take your time.
    • If you continue to be constipated, try taking processed or
      synthetic fiber (such as Citrucel, Metamucil, or Perdiem) each day.
    • If your stools are very hard, try taking a stool softener,
      such as Colace, to prevent straining.
  • Reach and stay at a healthy weight.
  • Avoid activities that stress your pelvic
    muscles, such as heavy lifting.

Medications

Although taking or applying the hormone
estrogen will not cure an existing
pelvic organ prolapse, it is sometimes prescribed for
women during
menopause to preserve or strengthen the tissues of the
pelvis, which may help prevent prolapse. Estrogen prevents drying and thinning
of the vaginal tissues (vaginal atrophy) and improves your ability to
effectively use a support device for your vagina (pessary).

Studies have shown that taking estrogen
therapy (ET) or hormone therapy (HT) can increase risks of
serious diseases. Estrogen as a low-dose vaginal
cream is not thought to pose the same risks to women's health. Talk to your
doctor about taking or applying estrogen.

Surgery

If you have pain and discomfort from
pelvic organ prolapse that does not respond to
nonsurgical treatment and lifestyle changes, you may want to consider surgery.
The choice of surgery depends upon which organs are involved, how bad your
symptoms are, and what other medical conditions are present. Also, your surgeon
may have experience with and preference for a certain procedure. The goals of
surgery are to relieve your symptoms and restore the normal functioning of your
pelvic organs.

There are several types of surgery to correct
stress urinary incontinence. These can be done at the
same time as surgery to repair prolapse. These surgeries lift the urethra
and/or bladder into their normal position.

Surgery choices

Surgical procedures used to correct different types of
pelvic organ prolapse include:

What to think about

Surgeries are designed to treat
specific symptoms, so you may still have other symptoms after surgery. An examination while you have a pessary in your vagina may help the doctor see if urinary incontinence would be a problem
after surgery. If the exam shows that urinary incontinence will be a
problem, another surgery can be done at the same time to fix the
problem.

Surgery in one part of your pelvis can make a prolapse
in another part worse, possibly requiring separate treatment in the
future.

Pelvic organ
prolapse is strongly linked to labor and vaginal delivery. So you may want to delay surgery if you plan to have children.

Other Treatment

You may be able to relieve
symptoms of
pelvic organ prolapse by using a pessary. A
pessary is a removable device that fits into your
vagina and supports the pelvic organs, helping to keep them in place.

What to think about

Many women can successfully
control symptoms of pelvic organ prolapse for years using a vaginal pessary.
But if you have a severe prolapse, you may have difficulty keeping a pessary in
place.

Other Places To Get Help

Organizations

American Urogynecologic Society
2025 M Street NWSuite 800Washington, DC  20036
(202) 367-1167
(202) 367-2167
info@augs.org
www.augs.org

The American Urogynecologic Society (AUGS) is the
premier society dedicated to research and education in urogynecology and in the
detection, prevention, and treatment of female lower urinary tract disorders
and pelvic floor disorders.

American Congress of Obstetricians and Gynecologists
(ACOG)
www.acog.org

References

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2017). Practice Bulletin No. 185: Pelvic organ prolapse. Obstetrics and Gynecology, 130(5): e234–e250. DOI: 10.1097/AOG.0000000000002399. Accessed November 15, 2017.
  • Deng DY (2008). Female urology and sexual dysfunction. In EA Tanagho, JW McAninch, eds., Smith's General Urology, 17th ed., pp. 611-624. New York: McGraw-Hill.
  • Feiner MC, et al. (2010). Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (5).
  • Gleason JL, et al. (2012). Pelvic organ prolapse. In JS Berek, ed., Berek and Novak's Gynecology, 15th ed., pp. 906–939. Philadelphia: Lippincott Williams and Wilkins.
  • Hamilton C, et al. (2015). Gynecology. In FC Brunicardi et al., eds., Schwartz's Principles of Surgery, 10th ed., pp. 1671–1707. New York: McGraw-Hill Education.
  • Lentz GM (2012). Anatomic defects of the abdominal wall and pelvic floor. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 453–474. Philadelphia: Mosby Elsevier.
  • Onwude JL (2012). Genital prolapse in women, search date August 2011. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
  • Reynolds RK, Loar PV (2010) Gynecology. In GM Doherty, ed., Current Diagnosis and Treatment: Surgery, 13th ed., pp. 966-984. New York: McGraw-Hill.
  • Winters JC, et al. (2012). Vaginal and abdominal reconstructive surgery for pelvic organ prolapse. In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol. 3, pp. 2069–2114. Philadelphia: Saunders.

Credits

ByHealthwise StaffPrimary Medical Reviewer Sarah Marshall, MD - Family Medicine Kathleen Romito, MD - Family Medicine Martin J. Gabica, MD - Family Medicine Specialist Medical Reviewer Femi Olatunbosun, MB, FRCSC - Obstetrics and Gynecology

Current as ofDecember 7, 2017

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